Wiki Patient has Medicare Part A only and secondary Humana; will Humana pay ?

[heartyoga]

We had a patient who either didn't understand her coverage or misrepresented her coverage. She said she has Humana primary and MCR Part A secondary.
She was in the hospital for 2 weeks. Our doctor took good care of her and when we submitted the claim, we were paid by Humana only 20% of allowable averaging $15-$20 per visit. However, we were never paid the 80% since MCR Part A won't pay. How do we appeal it?
Thanks.

 

[thomas7331]

Medicare Part A only covers inpatient facility claims - there is no coverage for physician charges so it will not do any good to appeal this. If the patient does not have part B coverage, and the secondary plan will only cover 20% of the allowable, then the patient would be responsible for the 80% balance. If you think that an error has been made in the way the benefits were calculated, then you could try appealing on behalf of the patient, but if it's simply a case that the patient does not have coverage to pay for the bills in full, then there's nothing to be done other than to try to collect from the patient.

 

[heartyoga]

Thanks

Thanks. We feel that Humana has been processing it incorrectly but we are not sure. BCBS of TN used to pick up what Medicare Part A doesn't pay. I'm trying to research on this issue but has come up blank. Can we compel Humana to cover physician services since Part A doesn't cover physician services? Humana has been difficult to work with.

 

[CodingKing]

is it a Humana Medicare Supplement? Medicare supplements will not pay as primary if no Medicare Part B. You may need to check the CPB provisions on the plan if its commercial. Some wont pay at all of medicare is primary and patient does not have part B. Only other possibility is they don't have proper COB information on file. I worked for a payer at one point we would pay 20% if patient was medicare aged and we didn't receive responses to inquiries about COB.